It’s day one of my period and I’ve been healing a broken foot for 6 weeks. The weather is overcast, thick, humid and rainy.
My body feels thick and heavy. Clothing leaves an imprint on my skin–socks leave deep indentations in my ankles. My face and foot is swollen. My tongue feels heavy. My mind feels dull, achey, and foggy. It’s hard to put coherent words together.
I feel cloudy and sleepy. Small frustrations magnify. It’s hard to maintain perspective.
My muscles ache. My joints throb slightly. They feel stiffer and creakier.
This feeling is transient. The first few days of the menstrual cycle are characterized by an increase in prostaglandins that stimulate menstrual flow and so many women experience an aggravation of inflammatory symptoms like depression, arthritis, or autoimmune conditions around this time. You might get. a cold sore outbreak, or a migraine headache around this time of month. The phenomenon can be exaggerated with heavy, humid weather, and chronic inflammation–such as the prolonged healing process of mending a broken bone.
Inflammation.
It’s our body’s beautiful healing response, bringing water, nutrients, and immune cells to an area of injury or attack. The area involved swells, heats up, becomes red, and might radiate pain. And then, within a matter of days, weeks, or months, the pathogen is neutralized, the wound heals and the inflammatory process turns off, like a switch.
However, inflammation can be low-grade and chronic. Many chronic health conditions such as diabetes, arthritis, PMS or PMDD, depression, anxiety, migraines, even bowel and digestive issues, have an inflammatory component.
In the quest to manage chronic inflammation, people often explore various avenues, including dietary supplements. One such natural option gaining attention is OrganicCBDNugs. Derived from the hemp plant, CBD, or cannabidiol, is believed to possess anti-inflammatory properties, potentially offering relief to those struggling with conditions like arthritis, anxiety, or migraines.
This organic supplement, with its purported ability to interact with the body’s endocannabinoid system, might provide a holistic approach to tackling inflammation-related issues. As we navigate the complexities of our bodies and the ebb and flow of inflammation, exploring natural remedies like Organic CBD could be a step toward finding equilibrium and promoting overall well-being.
As I telly my patients. Inflammation is “everything that makes you feel bad”. Therefore anti-inflammatory practices make you feel good.
Many of us don’t realize how good we can feel because low-grade inflammation is our norm.
We just know that things could be better: we could feel more energy, more lightness of being and body, more uplifted, optimistic mood, clearer thinking and cognitive functioning, better focus, less stiffness and less swelling.
Obesity and weight gain are likely inflammatory processes. Insulin resistance and metabolic syndrome are inflammatory in nature. It’s hard to distinguish between chronic swelling and water retention due to underlying low-grade chronic inflammation and actual fat gain, and the two can be closely intertwined.
It’s unfortunate then, that weight loss is often prescribed as a treatment plan for things like hormonal imbalances, or other conditions caused by metabolic imbalance. Not only has the individual probably already made several attempts to lose weight, the unwanted weight gain is most likely a symptom, rather than a cause, of their chronic health complaint. (Learn how to get to the root of this with my course You Weigh Less on the Moon).
Both the main complaint (the migraines, the PMS, the endometriosis, the depression, the arthritis, etc.) and the weight gain, are likely due to an inflammatory process occurring in the body.
To simply try to cut calories, or eat less, or exercise more (which can be helpful for inflammation or aggravate it, depending on the level of stress someone is under), can only exacerbate the process by creating more stress and inflammation and do nothing to relieve the root cause of the issues at hand.
Even anti-inflammatory over the counter medications like Advil, prescription ones like naproxen, or natural supplements like turmeric (curcumin) have limiting effects. They work wonderfully if the inflammation is self-limiting: a day or two of terrible period cramps, or a migraine headache. However, they do little to resolve chronic low-grade inflammation. If anything they only succeed at temporarily suppressing it only to have it come back with a vengeance.
The issue then, is to uncover the root of the inflammation, and if the specific root can’t be found (like the piece of glass in your foot causing foot pain), then applying a general anti-inflammatory lifestyle is key.
The first place to start is with the gut and nutrition.
Nutrition is at once a complex, confusing, contradictory science and a very simple endeavour. Nutrition was the simplest thing for hundreds of thousands of years: we simply ate what tasted good. We ate meat, fish and all the parts of animals. We ate ripe fruit and vegetables and other plant matter that could be broken down with minimal processing.
That’s it.
We didn’t eat red dye #3, and artificial sweeteners, and heavily modified grains sprayed with glyphosate, and heavily processed flours, and seed oils that require several steps of solvent extraction. We didn’t eat modified corn products, or high fructose corn syrup, or carbonated drinks that are artificially coloured and taste like chemicals.
We knew our food—we knew it intimately because it was grown, raised, or hunted by us or someone we knew—and we knew where it came from.
Now we have no clue. And this onslaught of random food stuffs can wreck havoc on our systems over time. Our bodies are resilient and you probably know someone who apparently thrives on a diet full of random edible food-like products, who’s never touched a vegetable and eats waffles for lunch.
However, our capacity to heal and live without optimal nutrition, regular meals that nourish us and heal us rather than impose another adversity to overcome, can diminish when we start adding in environmental chemicals and toxins, mental and emotional stress, a lack of sleep, and invasion of blue light at all hours of the day, bodies that are prevented from experiencing their full range of motion, and so on.
And so to reduce inflammation, we have to start living more naturally. We need to reduce the inflammation in our environments. We need to put ourselves against a natural backdrop–go for a soothing walk in nature at least once a week.
We need to eat natural foods. Eat meats, natural sustainably raised and regeneratively farmed animal products, fruits and vegetables. Cook your own grains and legumes (i.e.: process your food yourself). Avoid random ingredients (take a look at your oat and almond milk–what’s in the ingredients list? Can you pronounce all the ingredients in those foods? Can you guess what plant or animal each of those ingredients came from? Have you ever seen a carageenan tree?).
Moving to a more natural diet can be hard. Sometimes results are felt immediately. Sometimes our partners notice a change in us before we notice in ourselves (“Hon, every time you have gluten and sugar, don’t you notice you’re snappier the next day, or are more likely to have a meltdown?”).
It often takes making a plan–grocery shopping, making a list of foods you’re going to eat and maybe foods you’re not going to eat, coming up with some recipes, developing a few systems for rushed nights and take-out and snacks–and patience.
Often we don’t feel better right away–it takes inflammation a while to resolve and it takes the gut time to heal. I notice that a lot of my patients are addicted to certain chemicals or ingredients in processed foods and, particularly if they’re suffering from the pain of gut inflammation, it can tempting to go back to the chemicals before that helped numb the pain and delivered the dopamine hit of pleasure that comes from dealing with an addiction. It might help to remember your why. Stick it on the fridge beside your smoothie recipe.
We need to sleep, and experience darkness. If you can’t get your bedroom 100%-can’t see you hand in front of your face-dark, then use an eye mask when sleeping. Give your body enough time for sleep. Less than 7 hours isn’t enough.
We need to move in all sorts of ways. Dance. Walk. Swim. Move in 3D. Do yoga to experience the full range of motion of your joints. Practice a sport that requires your body and mind, that challenges your skills and coordination. Learn balance both in your body and in your mind.
We need to manage our emotional life. Feeling our emotions, paying attention to the body sensations that arise in our bodies—what does hunger feel like? What does the need for a bowel movement feel like? How does thirst arise in your body? Can you recognize those feelings? What about your emotions? What sensations does anger produce? Can you feel anxiety building? What do you do with these emotions once they arise? Are you afraid of them? Do you try to push them back down? Do you let them arise and “meet them at the door laughing” as Rumi says in his poem The Guest House?
Journalling, meditation, mindfulness, hypnosis, breath-work, art, therapy, etc. can all be helpful tools for understanding the emotional life and understanding the role chronic stress (and how it arises, builds, and falls in the body) and toxic thoughts play in perpetuating inflammation.
Detox. No, I don’t mean go on some weird cleanse or drinks teas that keep you on the toilet all day. What I mean is: remove the gunk and clutter from your physical, mental, spiritual, and emotional plumbing. This might look like taking a tech break. Or going off into the woods for a weekend. Eating animals and plants for a couple of months, cutting out alcohol, or coffee or processed foods for a time.
It might involve cleaning your house with vinegar and detergents that are mostly natural ingredients, dumping the fragrances from your cosmetics and cleaning products, storing food in steel and glass, rather than plastic. It might mean a beach clean-up. Or a purging of your closet–sometimes cleaning up the chaos in our living environments is the needed thing for reducing inflammation. It’s likely why Marie Kondo-ing and the Minimalist Movement gained so much popularity–our stuff can add extra gunk to our mental, emotional, and spiritual lives.
Finally, connect with your community. Loneliness is inflammatory. And this past year and a half have been very difficult, particularly for those of you who live alone, who are in transition, who aren’t in the place you’d like to be, or with the person or people you’d like to be–your soul family.
It takes work to find a soul family. I think the first steps are to connect and attune to oneself, to truly understand who you are and move toward that and in that way people can slowly trickle in.
We often need to take care of ourselves first, thereby establishing the boundaries and self-awareness needed to call in the people who will respect and inspire us the most. It’s about self-worth. How do you treat yourself as someone worthy of love and belonging?
Perhaps it first comes with removing the sources of inflammation from our lives, so we can address the deeper layers of our feelings and body sensations and relieve the foggy heaviness and depression and toxic thoughts that might keep us feeling stuck.
Once we clear up our minds and bodies, and cool the fires of inflammation, we start to see better—the fog lifts. We start to think more clearly. We know who we are. Our cravings subside. We can begin to process our shame, anger and sadness.
We start to crave nourishing things: the walk in nature, the quiet afternoon writing poetry, the phone call with a friend, the stewed apples with cinnamon (real sweetness). We free up our dopamine receptors for wholesome endeavours. We start to move in the direction of our own authenticity. I think this process naturally attracts people to us. And naturally attracts us to the people who have the capacity to love and accept us the way we deserve.
Once we start to build community, especially an anti-inflammatory community—you know, a non-toxic, nourishing, wholesome group of people who make your soul sing, the path becomes easier.
You see, when you are surrounded by people who live life the way you do–with a respect for nature, of which our bodies are apart–who prioritize sleep, natural nutrition, mental health, movement, emotional expression, and self-exploration, it becomes more natural to do these things. It no longer becomes a program or a plan, or a process you’re in. It becomes a way of life–why would anyone do it any other way?
The best way to overcome the toxicity of a sick society is to create a parallel one.
When you’re surrounded by people who share your values. You no longer need to spend as much energy fighting cravings, going against the grain, or succumbing to self-sabotage, feeling isolated if your stray from the herb and eat vegetables and go to sleep early.
You are part of a culture now. A culture in which caring for yourself and living according to your nature is, well… normal and natural.
There’s nothing to push against or detox from. You can simply rest in healing, because healing is the most natural thing there is.
Whenever I sit with a new patient for an initial intake, I ask about cravings.
From my many conversations about food, appetite and cravings, the most common responses are cravings for salt, or sugar, with many people falling on one end of the preference than the other: “I’m a salt craver” or “I’ve got a sweet tooth”.
However, cravings are so much more than that.
I believe that they are a beautifully intricate process, in which our body is trying to speak to us about what it needs.
Our bodies have developed taste receptors to detect quality nutrients from the environment. While these days sugar is abundant wherever you turn, during our hunter-gatherer times, it was a relatively scarce and highly sought after taste–the taste of ripe fruit, rich with nutrients, the taste of quality calories from carbohydrates, which may have been scarce in times of food shortage or famine.
Salt or “savoury” or umami cravings, often represent a need for more protein. Unfortunately, many of my patients who crave salt (and often calories) find themselves the bottom of a bag of chips, rather than grilling up a chicken breast.
Our modern environment doesn’t necessarily set us up to adequately translate and respond properly to certain cravings. Salted chips were probably not a thing in a natural environment and the only way to satisfy a salt and savoury craving would have been through hunting, consuming meat, or eggs and poultry.
When I was travelling in Colombia I was obsessed with broccoli–it was like I couldn’t get enough of it.
The same thing happened on a month-long trip to Brazil in 2019. Broccoli is rich in vitamin C, sulphur, and certain amino acids. It’s also a decent source of calcium. I’m not sure what nutrient I may have been lacking on my travels, but it’s possible that those cravings meant something for my body. And so I honoured them–I sought out broccoli like it was a magic elixir of health and ate as much of it as I could.
After developing significant iron deficiency after spending a few years as a vegetarian, I became suddenly attracted by the smell of roasting chicken from a local Korean restaurant I was passing by while walking the streets of Toronto.
The wafting smell of roasting poultry was majestic and impossible to ignore. It didn’t smell like sin, or temptation–my body betraying my moral sensibilities or whatever else we often accuse our cravings of—it smelt… like health.
There was no doubt in my mind as the delicious fumes touched my nostrils that I needed to honour my body and start eating meat again. I did and my health and nutrient status has never been better.
Patients will report craving carbs and chocolate the week before their period. The eb and flow of estrogen can affect serotonin levels. A large dose of carbs allows tryptophan, the amino acid that forms the backbone of serotonin, to freely enter the brain. This explains the effect “comfort foods” like starchy warm bread and pasta have on us, creating that warm, after-Thanksgiving dinner glow.
Chocolate is rich in magnesium, a nutrient in which many of us are deficient, that is in higher demand throughout the luteal phase of our cycle, or our premenstrual week.
Cravings are not just nagging, annoying vices, thrust in the path to greater health and iron discipline. They’re complex, intuitive and beautiful. They may be important landmarks on the path to true health and wellness.
Disciplines like Intuitive Eating and Mindful Eating have based themselves on the idea that our bodies hold intuitive wisdom and our tastes, cravings and appetites may be essential for guiding us on a road to health. Through removing restriction and paying more attention to the experience of food, we may be better guided to choose what foods are right for us.
The book The Dorito Effect outlines how our taste cues have been hijacked by Big Food. Like having a sham translator, processed foods stand between essential nutrients and the signals our bodies use to guide us to them. A craving for sweet that might have led you to ripe fruit, now leads you to a bag of nutrient-devoid candy that actually robs you of magnesium, and other nutrients in order to process the chemicals. A craving for salt and umami, or hunger for calories leads you to polish off a bag of chips, which are protein-devoid and laden with inflammatory fats, and only trigger more cravings, and shame.
It’s no wonder that we don’t trust our cravings– we live in a world that exploits them at every turn.
Clara Davis in 1939 was curious about the instintual nature of human cravings and devised a study that was published in the Canadian Medical Assoication Journal (CMAJ). The study was called Self-Selection of Diets by Young Children.
Clara gathered together 15 orphaned infants between 6 to 11 months of age who were weaning from breast-feeding and ready to receive solid food for the first time. These infants, before the study had never tried solid food or supplements. They were studied ongoing for a period of 6 years, with the main study process was conducted over a period of months.
The babies were sat at a table with a selection of simple, whole foods–33 to be exact. The foods contained no added sugars or salt. They were minimally cooked. Not all 33 were presented to each baby at each meal, however the babies were offered an opportunity to try everything.
The foods they were offered were water, sweet milk, sour (lactic) milk, sea salt, apples, bananas, orange juice, pineapple, peaches, tomatoes, beets, carrots, peas, turnips, cauliflower, cabbage, spinach, potato, lettuce, oatmeal, wheat, corn meal, barley, Ry-krisp (a kind of cereal), beef, lamb, bone marrow, bone jelly, chicken, sweetbreads, brains, liver, kidneys, eggs, and fish (haddock).
The nurses who were involved in running the study were instructed to sit in front of the infants with a spoon and wait for them to point at foods that they wanted. The nurses were not to comment on the choices or foods in any way, but wordlessly comply with the infants’ wishes and offer them a spoonful of the chosen foodstuff.
Throughout the study Davis noted that all the infants had hearty appetites and enjoyed eating.
At first, the babies showed no instinct for food choices, selecting things at random, and exploring the various foods presented to them. All of them tried everything at least once (two babies never tried lettuce and one never explored spinach). The most variety of food choices occurred during the first two weeks of the study when they were presumably in their experimentation phase.
Their tastes also changed from time to time, perhaps reflecting some hidden, internal mechanism, growth spurt or nutritional need. Sometimes a child would have orange juice and liver for breakfast (liver is a source of iron, and vitamin C from the orange juice aids in its absorption), and dinner could be something like eggs, bananas, and milk.
Many infants began the study in a state of malnourishment. Four were underweight and five suffered from Rickets a condition caused by extremely low vitamin D. One of the babies with severe Rickets was offered cod liver oil in addition to the other food options. Cod liver oil is a rich source of vitamin D.
The infant selected cod liver oil often for a while, after which his vitamin D, phosphorus and calcium blood levels all returned to normal range, and x-rays showed that his Ricket’s healed.
It is often thought by parents that children, if left to their own devices will eat themselves nutrient-deficient. While that may be true in todays’ landscape of processed frankenfoods, the infants in Davis’ study consumed a diet that was balanced and high in variety. They got 17% of their calories from protein, 35% from fat and 48% from carbohydrates and intake depended on their activity levels.
During the 6 years in which the infants’ eating habits were under observation, they rarely suffered from health issues. They had no digestive issues, like constipation. If they came down with a cold it would last no more than 3 days before they were fully recovered.
In the 6 years, they became ill with a fever only once, an outbreak that affected all of the infants in the orphanage. The researchers noticed their appetites change in response to the illness.
During the initial stages of the fever, they had lower appetites. And, once the fevers began to resolve, their appetites came back with a vengeance. They ate voraciously, and it was interesting that most of them showed an increased preference for raw carrots, beef and beets–which may indicate a need for vitamin A, iron and protein, which are needed for immune system function and recovery.
The habits of the infants to crave and select medicinal foods during times of fever and nutrient deficiency is such compelling evidence of Clara Davis’ craving wisdom hypothesis—were their bodies telling them what they needed to heal?
The self-selected, whole foods diets seems to have a positive impact on the mood and behaviours of the babies, all of whom were living full-time at the orphanage.
A psychiatrist, Dr. Joseph Brennemann wrote an article on them entitled “Psychologic Aspects of Nutrition” in the Journal of Pediatrics on their mood, behaviour and affect, “I saw them on a number of occasions and they were the finest group of specimens from the physical and behaviour standpoint that I have even seen in children of that age.”
In our world we often try to mentalize our food choices: going vegan or low-fat, counting calories, or reducing carbs. We time our eating windows, fast, or try to exert discipline and will over our bodies’ inherent desires.
So often my patients need to be coached through food eliminations, or given meal plans and templates. The art of listening to the body: properly identifying hunger, thirst, fatigue, inflammation, and even emotions like boredom, anxiety, sadness, anger, and hurt, can be a long process.
And yet, I wonder if we clear our palates and offer them a variety of whole, unprocessed, fresh foods, if our bodies will settle into their own grooves–perhaps our health will optimize, our bodies will be able to more readily communicate what they need, our taste receptors and cravings will adjust, and our cravings and appetite will serve the purpose they were meant to–to tell us what we need more of and what need less of or not at all.
I wonder if we listen, what our bodies will tell us.
I wonder if we let them, if our bodies will exhibit the pure instinctual wisdom of nature and the quest for harmony and homeostasis that lies at the heart of our natural world.
About a month ago I fractured my right 5th metatarsal (an avulsion fracture, aka “The Dancer’s Fracture” or a “Pseudo-Jones Fracture”).
As soon as I laid eyes on the x-ray and the ER doctor declared, “Ms. Marcheggiani,” (actually, it’s doctor, but ok) “you broke your foot!” things changed.
I have never broken anything before, but if you have you know what it’s like. In a matter of seconds I couldn’t drive. I could barely put weight on it. I was given an Aircast boot to hobble around in, and told to ice and use anti-inflammatories sparingly. My activities: surfing, skateboarding, yoga, even my daily walks, came to a startling halt.
I spent the first few days on the couch, my foot alternating between being elevated in the boot and immersed in an ice bath. I took a tincture with herbs like Solomon’s Seal, mullein, comfrey, and boneset to help heal the bone faster. I was adding about 6 tbs of collagen to oats in the morning. I was taking a bone supplement with microcrystalline hydroxyapatite, pellets of homeopathic symphytum, zinc, and vitamin D.
We call this “treatment stacking”: throwing everything but the kitchen sink at something to give the body as many resources as possible that it may use to heal.
My brother’s wedding came and went. I was the emcee, and the best man. I bedazzled my boot and hobbled around during set-up, photos, presentations, and even tried shaking and shimmying, one-legged on the dance floor. The next few days I sat on the couch with my leg up.
I watched the Olympics and skateboarding videos. I read The Master and the Margarita and Infinite Jest. I got back into painting and created some pen drawings, trying to keep my mind busy.
I slept long hours–an amount that I would have previously assumed to be incapable. The sleep felt necessary and healing. I was taking melatonin to deepen it further.
I closed down social media apps on my phone to deal with the immense FOMO and stop mindlessly scrolling. I journaled instead, turning my focus from the outside world to my inner one.
It was a painful process, and not necessarily physically.
I was confined to my immediate surroundings–not able to walk far or drive. I was at the mercy of friends and family to help me grocery shop. The last year and a half has made many of us grow accustomed to social isolation and a lot of my social routines from years prior had fallen by the wayside.
My world, like the worlds of many, had gotten smaller over the last 18 months. With a broken foot, my world shrunk even further.
The loneliness was excruciating.
It would come in waves.
One moment I would relish the time spent idle and unproductive. The next I would be left stranded by my dopamine receptors, aimless, sobbing, grieving something… anything… from my previous life. And perhaps not just the life I had enjoyed pre-broken foot, but maybe a life before society had “broken”, or even before my heart had.
I thought I would be more mentally productive and buckle down on work projects but it became painfully obvious that my mental health and general productivity are tightly linked to my activity levels. And so I spent a lot of the weeks letting my bone heal in a state of waiting energy.
My best friend left me a voicemail that said, “Yes… you’re in that waiting energy. But, you know, something will come out of it. Don’t be hard on yourself. Try to enjoy things… watch George Carlin…”
During the moments where I feel completely useless and unproductive, waiting for life to begin, I was reminded of this quote by Cheryl Strayed. This quote speaks to me through the blurry, grey haze of boredom and the existential urgency of wasting time.
It says,
“The useless days will add up to something. The shitty waitressing jobs. The hours writing in your journal. The long meandering walks. The hours reading poetry and story collections and novels and dead people’s diaries and wondering about sex and God and whether you should shave under your arms or not. These things are your becoming.”
These things are your becoming.
Something will come out of it.
When I did a 10-Day Vipassana (silent meditation) retreat in the summer of 2018, I learned about pain.
It was Day 3 or 4 and we had been instructed to sit for an entire hour without moving. The pain was excruciating. The resistance was intense. I was at war with myself and then, when the gong went off and there was nothing to push against, I noticed a complete relief of tension. I was fine.
The next time I sat to meditate (another hour after a 10 minute break), I observed the resistance and released it. It’s hard to describe exactly what I did. It was something like, letting the sensations of pain flow through me like leaves on a river, rather than trying to cup my hands around them, or understand or making meaning out of them.
The sensations ebbed and flowed. Some might have been called “unpleasant” but I wasn’t in a space to judge them while I was just a casual observer, watching them flow by. They just were.
And when I have intense feelings of loneliness, boredom or heart-break I try to remember the experience I had with pain and discomfort on my meditation cushion. I try to allow them.
“This too shall pass”.
When I have a craving to jump off my couch and surf, or an intense restlessness in the rest of my body, the parts that aren’t broken, I try to let those sensations move through me.
I notice how my foot feels. How while apparently still, beneath my external flesh my body is busy: it’s in a process. It’s becoming something different than it was before. It’s becoming more than a foot that is unbroken. It’s becoming callused and perhaps stronger.
Maybe my spirit is in such a process as well.
The antidote to boredom and loneliness very often is a process of letting them move through, of observing the sensations and stepped back, out of the river to watch them flow by. A patience. Letting go.
I can’t surf today. But, it is the nature of waves that there will always be more.
Pima Chodron in her book When Things Fall Apart also references physical pain and restless in meditation while speaking of loneliness.
She writes,
“Usually we regard loneliness as the enemy. Heartache is not something we choose to invite in. It’s restless and pregnant and hot with desire to escape and find something or someone to keep us company. When we can rest in the middle, we begin to have a nonthreatening relationship with loneliness, a relaxing and cooling loneliness that completely turns our usual fearful patterns upside down.”
She continues,
“When you wake up in the morning and out of nowhere comes the heartache of alienation and loneliness, could you use that as a golden opportunity? Rather than persecuting yourself or feeling that something terribly wrong is happening, right there in the moment of sadness and longing, could you relax and touch the limitless space of the human heart?
“The next time you get a chance, experiment with this.”
“The right to determine what shall or shall not be done with one’s own body, and to be free from non-consensual medical treatment is a right deeply rooted in Canadian common law. The right underlines the doctrine of informed consent.
“With very limited exceptions (such emergency use or incapacity), every person’s body is considered inviolate and accordingly every competent adult has the right to be free from unwanted medical treatment.
“The fact that serious risks or consequences may result from a refusal of medical treatment does not vititate the right of medical self-determination.
“The doctrine of informed consent ensures the freedom of individuals to make choices about their medical care. It is the patient, not the physician (or others) who ultimately must decide if treatment–any treatment–is to be administered.” Justice Robbins of the Ontario Court of Appeal.
I deeply believe that the key to optimal health is taking full responsibility and accepting all personal power for one’s own health. This may involve doing research, educating oneself, or assembling a team of trusted health professionals, with you, the patient at the centre.
We have a busy and overloaded healthcare system and even well-meaning professionals can find themselves hurriedly having a conversation in which they are not properly informing patients of the risks and benefits, or alternatives to treatment that they are recommending. I have had patients hurriedly scheduling for surgeries they weren’t sure they wanted, or pressured into hysterectomies or long-term treatments whose risks they didn’t understand.
I have also had patients make perplexing choices in the name of their own care–choices I didn’t necessarily agree with, such as forgoing conventional cancer treatments or further testing or screening.
However, it is the duty of the healthcare provider to provide advice. And it is the right of every patient to accept or reject that advice.
In light of recent, disturbing events, I have started posting some facts on Canadian law and Informed Consent only to be met with surprise–many people are not aware of their rights to refuse medical treatment, to be informed of the risks, and to be allowed to make a choice free of pressure or coercion.
Despite it being deeply enshrined in Canadian law, many patients are not aware of their right to full bodily integrity, autonomy, and choice.
Since 1980, the Supreme Court of Canada made it the right of every patient to be given full informed consent before any medical procedure such as taking blood, giving an injection or vaccination, performing a physical examination, exposing the patient to radiation, and so on.
“The underlying principle is the right of a patient to decide what, if anything, should be done with his body.” Is quote from the famous Supreme Court case of Hopp v. Lepp.
Every health professional under the Regulated Health Professions Act, including naturopathic doctors has a duty to uphold informed consent. We are well versed in it. We are required to uphold it, document it, and maintain it with every patient we see.
Our naturopathic guidelines on consent state, “The ability to direct one’s own health care needs and treatment is vital to an individual’s personal dignity and autonomy. A key component of dignity and autonomy is choice. Regulated health professionals hold a position of trust and power with respect to their patients and can often exercise influence over a patient; however, decision-making power must always rest with the patient.”
In 1996 Ontario passed the Health Care Consent Act, a legal framework for documenting, communicating, establishing and maintaining informed consent in all healthcare settings.
Informed consent is required before all treatment can be administered. Treatment includes: “anything that is done for a therapeutic, preventive, palliative, diagnostic, cosmetic or other health-related purpose, and includes a course of treatment, plan of treatment or community treatment plan.”
Informed consent must be present in 4 key areas:
The consent must relate to the treatment.
The consent must be informed.
The consent must be given voluntarily, i.e.: made by the patient, and under no coercion, pressure, or duress.
The consent must not be obtained through misrepresentation or fraud.
In order to obtain your full informed consent, you must be given the following information:
The nature of the treatment.
The expected benefits of the treatment.
The material risks of the treatment, no matter how small, especially if one of the risks of side effects is death. The risks should not be minimized for the purpose of influencing your decision-making. The risks should be in relation to your health history. For example, if you suffer from cardiovascular disease, you should be made aware of the the risk of blood clots or myocarditis. It should also be disclosed if certain risks remain unknown.
The material side effects of the treatment. Again, these side effects should be explicitly stated, no matter how small, and if long-term side effects are unknown, that should be stated.
Alternative courses of action.
The likely consequences of not having the treatment. These consequences should not be exaggerated and must be related to the particular patient at hand. What is the actual risk of the patient not receiving the treatment?
Consent cannot be given in a state of duress or coercion. Healthcare providers must be aware that they hold a position of authority and may maintain a power imbalance. They must not misrepresent the benefits of the treatment, and they must disclose any conflict of interest.
Healthcare providers must ensure that patients are not acting under the pressures of someone else, such as an employer, government agency or family member, and are making this decision on their own.
Finally,
The Informed Consent Guide for Canadian Physicians states, “Patients must always be free to consent to or refuse treatment, and be free of any suggestion of duress or coercion. Consent obtained under any suggestion of compulsion either by the actions or words of the physician or others may be no consent at all and therefore may be successfully repudiated. In this context physicians must keep clearly in mind there may be circumstances when the initiative to consult a physician was not the patient’s but was rather that of a third party, a friend, an employer, or even a police officer.
“Under such circumstances, the physician may be well aware that the paitent is only very reluctantly following the course of action suggested or insisted upon by a third person. Then, physicians should be more than usually careful to assure themselves that patients are in full agreement with what has been suggested, that there has been no coercion and that the will of other persons has not been imposed on the patient”.
It is your body and it is your choice. You always have the right to do what’s best for you. True, empowered health cannot come from a place of coercion or pressure.
Know that you always have a choice–your doctor has a duty to inform you of your choice, as well as the information necessary for you to make the right choice for you, regardless of what is happening in the media or in politics.
I was sitting with my friend and her ex-partner. Their kids are soccer stars–one is headed towards a professional career and the younger one is not far behind.
My friends ex-partner, a fit soccer fan himself, lamented, “I’m getting old. I don’t recover like I used to. I’m not as fast as I used to be. I feel more sore after a game of soccer now in my 40s than when I was in my teens and 20s. Getting old sucks.”
“When you were younger you played soccer everyday,” my friend retorted. “Is it that you’re getting old or is that, as an adult, you have more obligations and responsibilities than you did when you were in your teens and yet expect yourself to be able to pick up the sport and play once a week as hard as when you were playing everyday?”
We blame old age on everything in our society.
I’m tired of “you’re getting older” being the main throwaway diagnosis of my friends, family, and patients’ sliding health and fitness. Kelly Slater is almost 50–he plans to keep surfing into his 70s. I’ll bet he can, too.
Coco is like 70 in dog years and climbs steep hills and races and chases and bites (with the 5 teeth he has left) like a puppy.
As adults, I think we need to take responsibility for our bodies and take our range of motion, flexibility and strength seriously if we’d like to retain the physical mobility of our youth. It’s not your age—it’s what your age means to your movement patterns that will dictate your injury susceptibility, your recovery, your progress in your sport of choice, and your overall fitness and health.
I’ve been thinking about this lately because I’ve been taking my surf training a bit more seriously this year.
Surfing is an incredibly difficult sport. Tiny increments in progression happen over years, not months. Going from a beginner (which I would classify myself as: an advanced beginner) to an intermediate surfer is a timeline of almost daily sessions for at least a couple of years.
I’ve been surfing for two years and still have massive leaps and bounds to go before I’d classify my skills as “intermediate”.
Because the lakes don’t offer as much consistency as the ocean, I figured I wasn’t going to make progress fast enough unless I started to do dry-land training, focusing on physical strength for paddling and speed pumping down the line, and flexibility and mobility to be able to put my body in the positions that the sport demands–this means core strength, glute strength, hip and ankle flexibility and upper body strength.
It also means balance and practicing upper and lower body coordination.
It means I need to practice certain movement patterns on dry land, and train on a surfskate. It means I need to make sure my body has the range of motion necessary to surf, and the joint and muscle health necessary to recover faster, and prevent injury. It’s not fun to get injured as an adult when you have a job to go to that pays the bills.
I dislocated my shoulder at age 20 while snowboarding and it affected my ability to study effectively at university. My shoulder still gives me trouble, particularly if I put it in “backstroke” position, internal rotation and overhead extension– I can feel it slide out, in danger of redislocating. I don’t want another injury in my 30s.
I’ve also been watching the Olympics and thinking of professional surfers like 19-year old Caroline Marks. Her prodigy-like talent comes from a combination of learning the sport early in order to instil proper motor patterns, a competitive spirit, familial encouragement, financial resources, body type (a strong lower body and lower centre of gravity), and amazing coaching.
According to William Finnegan it’s almost impossible to be “any good” at surfing if you start learning after the age of 14.
Damn.
However, learning new movements and teaching your body how to coordinate in new ways does wonders to stave off depression and dementia as well as keep your body strong and supple.
I find focusing on performance in a sport helps with my body image: I focus on how my body looks in its postures and positions while performing the sport vs. the shape of it in general.
I also find the dopamine hits and adrenaline highs are addictive and calming—If I go too long without surfing I feel a bit if ennui-like withdrawal.
I also find that surfing is an amazing way to connect me with a community, with nature, with the lakes and the ocean, and my breath and body.
And I find it satisfying to work towards goals.
As a kid I was fairly athletic but not particularly talented at any competitive sport. I did gymnastics for a second, and played soccer for a number of years. I was on the swim team in high school and taught and coached swimming myself. I am still a strong swimmer but was nothing more than an average racer.
I was on the triathlon team at Queen’s for a couple of years, and had a job as a snowboarding instructor throughout high school. I loved snowboarding during that time until going to school in a relative flat place and suffering an injury drastically reduced the amount of time I was able to spend on the hill.
I’ve been fascinated about the technical aspect of skills I’m interested in acquiring.
I love learning what the optimal stance is and how to position my body to mimic it. I’m interested in learning how to breathe right, which muscles need stretching and which ones need strengthening.
I love the video analyses and the tips from friends on how to improve. I enjoy the struggle and the frustration and the plateaus followed by random bursts of improvement that fill you with giddy excitement. That slam dunk, arms in the air feeling.
When taking a history, I always ask patients about their physical activity levels and their movement patterns.
Many are physically active in order to support their health: walking daily, going to the gym to lift weights or take exercise classes, doing yoga or pilates. But many will tell me that their activity comes mostly from playing sports–they play hockey or golf once a week.
And many of my surfing friends just surf.
That’s fine if you’re like my friend Steve who surfs or skateboards virtually everyday, but if you’re the type of athlete who only has the time or opportunity to engage in your sport once a week or less you’re most likely putting yourself at risk of injury without any dry-land functional training.
Functional movement helps our bodies stay optimally healthy and… well, functional. The functional movements include pushing, pulling, squatting, lunging, twisting, gait, and rotation. We need them to stay mobile and injury free. I read somewhere that most 50 year olds can’t stand in a lunge position.
I know that many people in their 30s can’t sit crosslegged on the floor, or squat. Our hip flexors are tight, our glutes are loose, and our ankles are immobile. We aren’t training our bodies for functional existence, like sitting on the floor and standing up out of a chair without using your hands.
It’s important to stretch daily to prevent muscle and joint injury. It’s important to keep certain muscles strong–like the upper body muscles for paddling. Our bodies weren’t meant to perform repetitive movements on demand after staying locked in a shed for weeks. They need to move regularly and need to stay tuned up to perform the sport of your choice, especially if you’re still interested in progressing at it.
Many sports are asymmetrical as well. This can leave us vulnerable to injury as certain flexors are tighter than their extensors, and so on, putting strain on joints.
Being able to move your body through space, not just linearly, in 2D, like in running or walking, but across all dimensions: front and back and side to side and twisting and jumping and crawling, is important for maintaining proprioception and body awareness.
Open hip flexors (can you do a squat? Can you sit cross-legged on the floor? What about Pigeon Pose?) are important for maintaining optimal back and digestive health.
The glutes are the most metabolically active muscles in the body and for most of us they just lie around flaccid all day as we sit in our chairs and work on our computers. This causes tightness and strain in other areas of the body such as the hip flexors, calves and hamstrings.
I noticed that my left calf was so tight it was impacting my ankle flexibility. I learned this through yoga–noticing that when I would try to get into skandasana (side lunge), my heel wasn’t able to touch the floor on the left side. This left ankle tightness is inevitably going to impact my surfing because my body cannot literally get into the posture necessary for certain maneuvers and therefore will limit my progress.
And so I’ve been focusing on more sport-specific dry land training for the sport of surfing–a challenging feat to take on as someone in her mid-30s who doesn’t live near an ocean–but also to maintain optimal health, body awareness, and functional movement.
Challenge you body and brain through finding a sport you love, or activities that you love that you’d like to get better at. Train for these activities, stretch daily and begin to explore your body in new ways: learn what muscles need loosening and what muscles need strengthening, Begin to expand the range of motion of your joints to prevent injury.
Strengthen your bone mass through applying repetitive stress to long bones (through walking, running, jumping and weight-lifting).
Explore fluidity of movement through swimming, dance, yoga, pilates, or other activities that require complex movements, coordination, grace, style, and flow.
Watch your body shape transform into something you are genuinely proud of: not so much because of what it looks like, but for what it is capable of, how it supports you, and what it can do.
Develop and hone your body awareness. Deepen your breath. Pay attention to pain and physical sensations, including the physiological sensations of hunger, thirst, and fatigue. Body awareness can help to heal injury, process trauma, and engage in self-care. It can help with emotional regulation, and interpersonal relationships.
And, most of all, stay active. Whatever you do, find joy in movement.
It’s mulberry season, which means while walking through my neighbourhood I can snack, picking food right off the trees growing behind fences or on people’s front lawns whenever I walk by a berry-stained sidewalk.
There’s something therapeutic about entering into the flow state of berry-eating from a tree (or a bush? they’re massive bushes. The act of eating becomes a ritual. It demands presence and attention. It becomes like a game, the objective is looking for rich colour, ripeness, size, and strategizing how to access the delicious, prized morsel you’ve laid your eyes on, then savouring the experience of having attained it, before beginning the process again.
It’s impossible to binge-eat this way.
I remember at my friend’s cottage last Septemeber it was blueberry season and we spent the weekend casually hanging out in the middle of blueberry patches. I would find an abundant bush, settle down in the midst of it and graze. I must have eaten 5 cups of blueberries each day and yet it took me the entire day to do it.
What better way to spend a day?
The best part of it was: I met my food.
I was listening to Paul Saladino of the Fundamental Health Podcast interview Daniel Vitalis from the Rewilding Podcast. The subject came up about foraging, and hunting and meeting your food.
“Some people have never seen a bass,” Daniel Vitalis commented.
“Maybe not in the wild, maybe not in a zoo. They don’t know how big it is, what colour it is, what kind of lakes it lives in, what it looks like.
“And, more importantly, even if someone fishes for bass or knows what they look like, if they eat bass in a restaurant or from a frozen filet they’ve bought at the grocery store, they most likely haven’t met that bass.
“There’s a massive disconnect in our society between us and the food we eat.”
In almost every other culture we would have shared an intimate relationship with food.
When I was eating blueberries I took the time to settle down in a patch of bushes and linger. The act of eating was immersed in a ritualistic past-time. I was connecting with the specific plant whose food I was borrowing. I was visiting her home–her environment.
When you fish for bass, or hunt a deer, you enter that animal’s setting. You meet it alive. You witness it living. You witness it dying.
The animal’s fate intertwines with yours.
Your survival and his become like a seesaw. Yesterday it was your turn. Today it’s mine.
I suppose the fish filet’s fate is also intertwined with yours: he may have been destined to end up in the freezer section of the local Costco, but somehow… it seems radically different, largely impersonal. Colder.
This is why we obsess over food sometimes: where was the bass made? Was it caught or farmed? Is it organic? Where was it processed? Eating animals is wrong—I’m going to go vegan. And so on.
I believe that this neurosis becomes our remedy for disconnect, for the disembodiment we experience. Eating becomes an intellectual task. We need to read labels, visit websites, and do research, rather than just experiencing our food first in its living form, before engaging in the eating of it.
Hunter gatherers don’t read labels. They don’t diet.
The Hadza from Tanzania don’t have food rules, restrictions ,or even mental, nutritional concepts about food. That’s a Western thing.
The Hadza, like many other cultures more connected to their food sources, simply possess the raw biological desire to eat whatever and however much they like that they can get, whenever they can get it. They are guided by taste and hunger.
Their lives revolve around hunting and gathering food. They simply immerse themselves in their food environments and eat.
We are also immersed in a food environment: the packaged, fried, doctored foodstuffs packed into grocery stores, fast food restaurants, gas stations, and convenience stores. These foods connect with our hunger cues and communicate with our tastebuds but offer none of the impact of “real” food on our physiology. They don’t nourish us.
They don’t connect us to the natural world. They don’t encourage ritualistic eating. What happened to that wheat sheaf or corn blade for it to become refined flour or hydrogenated oil? Could I participate in the making of it? Or do I lack the chemicals and technology to process this food to make these potato chips, bread, or cookies?
Our food environment encourages our disconnect and this encourages our neurosis around food and nutrition. In order to thrive in this environment we need to think about food. We need to read labels and make choices and abstain from certain foods, and make an effort to change our environment so that it becomes one more conducive to human nourishment.
We need to refuse foods served to us at events, or buy separate groceries, and make separate meals for our partners or children.
We create a food “island” for ourselves, in the midst of our community.
And this becomes impossible.
You are only as healthy as the group and environment you find yourself in.
So what can we do? Perhaps we can start with community. Where do the healthy people shop? Where do you feel most connected to your food? Is it in your garden? Is it visiting a farm? Hunting or buying meat from a hunter, or a farm? Can you meet your meat before you buy it? Can you develop a relationship with those who grow or process your food?
Perhaps it means more at-home food preparation. Visiting more farmer’s markets. Talking with the people selling you your eggs. Perhaps it means developing a connection with a local farm where you source your food. Perhaps it means you pick your apples in season, or you grow your own herbs. Maybe you bake bread with your children, or can your own tomatoes.
Maybe you develop your own food and eating rituals and you practice them as a family or as a community.
Maybe you ask some questions about your food–what does this bass look like? How did this cow live?
Food has always been so central to human culture.
When we connect with the rituals of picking, hunting, growing, processing, and consuming our food, we learn what it is to be truly human.
That feeling that you can’t settle. You can’t eat. You can’t relax. Your muscles are tense.
Not all is right with the world. Many people who live with chronic low-grade anxiety don’t even realize it’s there.
I see this all the time in my patients who experience panic attacks (when a couple of straws “break the camel’s back” so to speak, the “backs” being a nervous system that is already tightly wound up), or dissociation, even depression, or chronic exhaustion.
Chronic low-grade anxiety can occur if something happens to us that our nervous systems don’t yet understand. I was babysitting a dog for a few days and she and my dog got into a fight. It was nasty and it rattled my nervous system.
I found myself feeling wound up… needing to be soothed, to be settled, for someone to tell me that it wasn’t going to happen again. My response is to go into “information” mode, to poll people, to get an authority’s perspective.
But, of course, it’s impossible to have certainty in this world. And so, my nervous system was asking for something: either that the situation wouldn’t happen again, or that I would know how to handle it and make things alright if it did.
Those with a history of childhood trauma may live in a state of hypervigilence and chronic anxiety–for you it might be your default state, like oxygen, anxiety is always there, at the very baseline of your experience.
The experience of low-grade anxiety is terrible. You’re always vigilant. You’re obsessing, you can’t relax. Your startle reflex is completely uptight.
You have nightmares, you don’t feel hungry. And yet you suddenly feel light-headed and starving.
Everything feels like too much.
Symptoms of chronic low-grade anxiety:
brain fog
overwhelm
disrupted sleep
feeling jittery or shaky
nausea
lack of hunger
extreme hunger
tense, sore muscles
digestive issues, IBS, bloating, diarrhea
generalized sense of dread
shortness of breath, or difficulty getting a full breath
sweating
fatigue
and so on
How do you heal it? Well, it’s tough because ultimately the nervous system wants you to REASSURE it that the world is a SAFE PLACE.
And… it’s not.
Shit happens.
It’s a bumper sticker for a reason.
Shit happens and when it does we need resources.
These resources come in the form of physical nutrition: literally salt, glucose and water. They come from stable hormones (related to blood sugar, a properly functioning circadian rhythm), managed inflammation.
They come from restorative practices: exercise and rest, time where you feel into your body. And they come from understanding the situation: storying it.
In the case of the dogfight, it helped me to learn about dogs, to know how to keep them calm and happy, to understand their particular language and establish myself as the dog leader (also lots and lots of exercise and a bit of CBD oil).
Once they were calm I was calm too.
In the case of childhood trauma it might involve working with the story through the support of a trusted therapeutic relationship, and maybe after working on building resources and engaging in stabilizing practices that help you feel embodied.
Therapies to treat chronic low-grade anxiety:
nutritional practices focused on obtaining essential nutrients like fat and protein and stabilizing blood sugar
support circadian rhythms, sleep and cortisol responses in the body
support neurotransmitters and cell membranes
trauma-informed therapy, or Cognitive Behaviour Therapy
movement
meditation and self-compassion
breathwork
emotional regulation, self-soothing and other embodiment practices
time in nature
plenty of rest
regular routines and self-care-informed habits
plant medicines that can help access deeper seated trauma or regulate the nervous system, hormonal systems and brain chemistry.
And so on.
Our nervous systems are beautiful things. They’re trying to tell us something.
A nervous system on edge is telling us that all is not harmonious with the world: perhaps our internal world, or our external one.
I talk with Dr. Kara and Dr. Dave of That Naturopathic Podcast, rated in the top 6 Canadian Medicine podcasts, about taming the tiger of anxiety. Click to learn about your HPA Axis, the stress response and how we can “tame the tiger” by providing our body and mind with the assurance that we’re safe. Listen on Spotify.
I talk to Taylor Morozova of the Weird Waves Podcast about how I became a naturopathic doctor, surfing, immunity, vitamin D, and how to stay safe in the age of Corona. Listen on Spotify.
In September of 2019, Jakobsen, Gluud and Kirsch published a review in the British Medical Journal: Evidence-Based Medicine entitled “Should antidepressants be used for major depressive disorder?” (1)
Their conclusion was this:
“Antidepressants should not be used for adults with major depressive disorder before valid evidence has shown that the potential beneficial effects outweigh the harmful effects.”
Now, before we move on with what drove them to make this seemingly radical conclusion, I want to be clear:
I am not stigmatizing medication.
All of those who take medication for depression have asked for help.
Asking for help is important.
Asking for help is brave.
And, whatever help works for you is the right kind of help.
But imagine this; imagine you are a pretty decent swimmer.
You’ve practiced swimming all your life. You’ve gotten lots of experience swimming in pools, lakes, and oceans. You know how to swim, just like you know how to cope with turmoil. But, despite your strength, one day you find yourself drowning.
“No, I’m not drowning,” you might say at first. “I can’t be drowning. I know how to swim! If I’m drowning, it means I’m a failure…
“What will everyone think?”
And so you continue to splash around a bit, until it becomes undeniable. You gasp some water-filled air. Your head submerges and you think, indeed, “I’m drowning.”
When you get your head above water you call for help.
This takes a lot.
It’s not easy to admit that you need help.
It’s not easy to overcome that little voice that tells you that asking for help is troubling other people, admitting defeat, showing weakness—and whatever else that darned little voice thinks it means.
“HELP!” You exclaim, louder this time—little voice be damned.
“HEEELP!”
And someone on shore sees you. They have a life-preserver in their hands and they throw it your way.
Your shame is peppered with relief—and gratitude: there’s an answer to all this suffering. You thrust your hand towards the life preserver, grasping it with a firm bravery.
Only, it starts to sink. It’s full of holes.
“What’s the matter?” The person waiting on the shore exclaims, as you continue to struggle, “Don’t you want help?”
The shame returns. Hopelessness joins it.
I advocate for mental health awareness. I advocate for perpetuating the message that it’s ok to talk about mental illness. It ok to admit you need help.
I believe the following:
Depression is not a a sign of weakness.
It’s not a sign that you are defective.
It’s not a sign that you haven’t learned proper coping skills, or that your coping skills are defective, or that you’re fragile.
It’s also not fixed by simple solutions like eating salad, running or putting “mind over matter”.
Depression happens to a lot of us.
It affects 300 million people globally. It is the leading cause of disability world-wide, with a lifetime prevalence of 10 to 20%. This means that 1 in 5 people will experience depression in their lifetimes.
We all know someone who suffers. Maybe you suffer.
And a lot of people ask for help. The National Health and Nutrition Examine Survey (NHANES) in 2017 found that 1 in 8 people over the age of 12 are taking an anti-depressant, a 65% increase over the last 15 years.
This means that 65% more of us are asking for help.
That’s a lot of life preservers.
So, just how effective is this help?
First, we need to understand how the efficacy of anti-depressants are measured.
The symptoms of depression are subjective. This means they are not observable. There is no imaging that shows if someone is depressed. There are no blood tests for depression. There are no physical exams.
Therefore, to assess the presence and severity of depression, clinicians use questionnaires. The most commonly used depression questionnaire is The Hamilton Depression and Rating Scale (HDRS), a 52-point checklist that assesses various symptoms of depression and rates them on a scale of no-depression to severe.
When patients with depression first see a family doctor or psychiatrist they are often issued the HDRS and given a score.
Let’s use Janet’s story as an example. Janet first came to see her psychiatrist two years ago. She wasn’t sleeping and yet felt sleepy all the time. She’d gained weight but had no appetite. Her entire body was sore, as if she had the flu. She’d lost interest in all of the activities that used to fire her up. She’d lost interest in everything.
After a few weeks of feeling progressively worse, Janet began to be plagued by thoughts of suicide. This scared her. She went to her family doctor, who referred her to a psychiatrist.
Janet’s HDRS score was 25. This meant she was moderately to severely depressed.
Janet was given an anti-depressant, a Selective Serotonin Re-uptake Inhibitor (SSRI). She was told it would correct her “brain imbalance”, and treat the cause of her symptoms. Janet was relieved that there was a solution.
If an anti-depressant can decrease the HDRS by 3 points, then the medication “works”. Or at least the results are statistically significant.
However, if Janet’s symptoms improve by 3 points, from a score of 25 to, say, a score of 22, how does she feel?
Not much different, it turns out.
To experience “minimal improvement”, a decrease in symptoms that someone with depression would notice, say an increase in energy, an improvement in sleep, or a change in mood, a patient’s HDRS score would need to decrease by at least 7 points.
This means the Janet would need to bring her HDRS down to 18 or lower before she starts to feel noticeably better.
Studies show that anti-depressants, on average, don’t do this.
Some randomized control trials do show that anti-depressants decrease the HDRS score by at least 3 points, which is still registered by patients as having no perceptible effect, but the results are mixed.
A large 2017 systematic review showed that anti-depressants only decreased patients’ HDRS by about 1.94 points (2) and another large study published in the Lancet (3) also failed to show that anti-depressants produce a statistically significant effect, let alone a clinically significant one.
In addition to the minimal changes in symptoms, anti-depressant research is also polluted with for-profit bias. Most studies are conducted or funded by the drug companies.
This makes a difference: an analysis showed a study was 22 times less likely to make negative statements about a drug if the scientists worked for the company that manufactured it (4).
Studies at high-risk of for-profit bias were also more likely to show positive effects of a drug (5).
Another limitation of anti-depressant trials is the lack of active placebo control. In Randomized Control Trials, participants are sorted into two groups: an active group, in which they receive the medication, and a placebo group, in which they receive an inert pill.
The goal of this process is to control for something called the “meaning response”, or “placebo effect” where our expectations and beliefs about a therapy have the potential to affect our response to it.
Remember that depression, as I mentioned before, is a condition made up of subjective symptoms.
If I asked you to rate your energy on a scale of 1 to 10, how would you rate it? What if I asked you tomorrow? What if I asked you after giving you a drink of something that tastes suspiciously like coffee?
Because of its subjective nature, and the subjective questionnaires, like the HDRS, that measure it, depression is very susceptible to the placebo response.
Therefore, it’s important to control for the placebo response in every trial assessing anti-depressants.
But it might not be enough to just take a sugar pill that looks like an anti-depressant.
SSRI medication produces obvious side effects: gastrointestinal issues, headaches, changes in energy, and sleep disturbances, to name a few.
When a patient taking a pill (either placebo or active treatment) starts to feel these side effects, they immediately know which group they have been randomized to, and they are no longer blinded.
This can be solved by giving an “active placebo”: a placebo that produces similar side effects to the active medication. Unfortunately anti-depressant trials that use active placebo are lacking.
But what about the people who DO benefit from anti-depressants?
Janet knew a few. She had a cousin who also suffered from depression. He took medication to manage his symptoms. He’d told her many times that he just wasn’t the same without it.
Perhaps you, reading this article have found benefit from an anti-depressant medication. Perhaps you know someone who has: a family member, or a friend. Maybe it was their lifeline. Maybe it’s yours.
According to Jakobson et al., there are indeed some people who benefit from anti-depressants. Anecdotally we know this to be true. However, the results of large studies show minimal to no benefit from medication, on average.
This means that some people might benefit; we know that some do. It also means that an equal number of people are harmed.
In order for the net effect of anti-depressant medication to be close to zero, an equal number of people experience negative effects that outweigh the positive effects seen in others.
So, while some may have already tried medication and benefited from it, those considering medication won’t know if they’ll be in the group who benefits, or the group who is harmed.
The side effects of anti-depressant medication are often underrepresented. In the Lancet study, adverse effects were neither recorded nor assessed (3).
The most common side effects include gastrointestinal problems, sleep disturbances, and sexual dysfunction. More serious side effects, like increased risk of suicide, are also possible. Some of these effects may persist even after the medication is stopped.
Anti-depressant trials are short-term. Most trials assess patients for 4 to 8 weeks, while most people take anti-depressants for 2 years or longer.
Anti-depressants also put people at risk of physiological dependence and withdrawal.
Withdrawal symptoms can occur a few days, or even weeks, after tapering anti-depressant medication. They sometimes last months.
Withdrawal symptoms are often mistaken for depressive relapse. This can make it difficult, or even impossible, for patients to come off medication. This is worrisome considering the lack of research on long-term medication use.
It is sometimes argued that anti-depressants are more effective, or even essential, for severe depression, however the evidence for this is lacking (4).
In their paper, Jakobson, Gluud and Kirsch conclude that, based on the evidence, anti-depressants show a high risk of harm with minimal benefit.
Before prescribing them, Jakobson et al recommend more non-biased, long-term studies that use active placebo, and honestly assess the negative effects of the medications.
They recommend that studies use improved quality of life and clinically meaningful symptom reduction, not just statistical significance, as standards for treatment success.
Despite these conclusions, SSRIs remain a first-line treatment for major depressive disorder. They are also prescribed for conditions like severe PMS, IBS, anxiety, grief, and fibromyalgia, or other pain conditions. 1 in 8 adults in North America are taking them.
As a clinician who focuses in mental health, I am not against medication.
I have seen patients benefit from SSRI or SNRI medications. Sometimes finding relief with medication when nothing else worked.
My clinical practice keeps me humble.
If a patient comes into my practice on medication, or considering medication, I listen. I ask how I can support them. I answer questions to the best of my ability. I trust my patients.
Patient experience trumps clinical papers.
However, for every patient who benefits from medication, just as many experience negative side effects, or no effect. I trust their experiences too.
I also trust the experiences of the patients who have been trying for months, or years, to wean off medications.
Let me repeat it again: depression is real. Asking for help is hard. And it’s important.
Depression is a multi-factorial condition.
This means that it stems from hundreds of complex causes. This is why it’s so difficult to treat. This is why so many people suffer.
Let me also repeat: depression is not easily fixed.
There is no one solution, and there are certainly no ONE-SIZE-FITS-ALL solutions.
So, if you or someone you care about is suffering from depression, what can you do?
First, get help. This is not something you can get through alone.
Second, seek lots of help: gather together a team of professionals, family and friends. You can start with one person: your family doctor or a naturopathic doctor, and then assemble your support network.
Choose people you trust: people who listen, provide you with options, and seek your full informed consent.
It is important to work with a healthcare team who take into account the factors that may be contributing to your symptoms: brain health, gut health, life stressors, nutrition, inflammation levels, presence of other health conditions, sleep hygiene, family history, contributing life circumstances, such as grief, trauma, or poverty, and who lay out various treatment options while filling you in on the risks, benefits and alternate therapies of each.
Medication may be part of this comprehensive treatment plan, or it may not.
It is brave to ask for help.
And I believe that bravery should be rewarded with the best standard of care—with the best help.
References:
Jakobsen JC, Gluud C, Kirsch IShould antidepressants be used for major depressive disorder?BMJ Evidence-Based Medicine Published Online First: 25 September 2019. doi: 10.1136/bmjebm-2019-111238
Jakobsen JC, Katakam KK, Schou A, et al. Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and trial sequential analysis. BMC Psychiatr2017;17:58
Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet2018;391:1357–66
Kirsch I, Deacon BJ, Huedo-Medina TB, et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the food and drug administration. PLoS Med2008;5:e45.doi:10.1371/journal.pmed.0050045
Ebrahim S, Bance S, Athale A, et al. Meta-Analyses with industry involvement are massively published and report no caveats for antidepressants. J Clin Epidemiol2016;70:155–63.doi:10.1016/j.jclinepi.2015.08.021
